What is Quality in Medicine? – It Isn’t Easy!

I remember quality once being referred to as a paraphrase of Justice Stewart Potter’s statement referring to pornography as , “something I can’t define, but, I’ll know it when I see it”. When applied to medicine, this type of definition is, unfortunately, completely unsatisfactory. Quality should be something that can be defined and measured. However, even today, quality is largely in the eye of the beholder. Some of the stakeholders who may have a unique perspective on what comprises medical quality include:

• Physicians
• Patients
• Other caregivers (extenders)
• Nurses
• Families
• Employers
• System/Hospital Administrators.
• Researchers and other Academics
• Payers (Governmental or Private Insurers)

A patient may view quality in terms of the way he or she gets to see a provider including such factors as: ease of getting appointment, attitude of para professional staff, whether the physician or staff are on time (how much leeway is acceptable is defined by the individual), the provider’s manner and personality, among others. A physician, on the other hand, is likely to view quality in terms of his/her training (specialist or generalist), his use of scientific evidence as it is published, his knowledge and familiarity with the most recent innovations, and perhaps in some instances his outcomes. Most physicians have probably not been rigorous in keeping track of their individual outcomes, in spite of Feinstein’s admonition to keep such records[1] A third group, outside bodies such as the federal government’s Centers for Medicare and Medicaid Services (CMS), or the Joint Commission (JC – previously the Joint Commission on Accreditation of Healthcare Organizations – JCAHO) often look at individual processes (drugs, counseling, and some procedures) that are done for specific conditions (often called by hospital personnel as “core measures”). Nurses often view quality as how promptly patients are seen and how their complaints are addressed. They always have an opinion on the quality of care provided by physicians, hospitals and other providers. It has been my experience that in the short run, nurses are more often “spot on” than not.

These, often subjective, measures can be quantified and made comparable between organizations and providers. One of the early attempts at defining quality was proposed by Avedis Donabedian in his construct that Quality was related to 1.) Structure (physical plant, institutional culture, and others); 2.) Process (what was delivered/performed) and 3.) Outcomes (mortality, morbidity, quality of life)[2],[3].

Q = S*P*O

The Institute of Medicine, in 2001defined six domains of an effective health care system, which is a surrogate for quality: Safety, Effectiveness, Patient Centricity, Timeliness, Efficiency and Equity[4].

As a physician, I have often been asked about the quality of another physician’s or surgeon’s practice. I often give an answer, but have become increasingly uneasy about the empiric basis of my recommendation. I almost never know a surgeon’s mortality rates (early or late), infection rates, or even his/her long-term efficacy rates. What I do know is how I think her/his judgment seems to be like (how often it improves my own judgment/recommendation), her/his personality (how we get along), what others of my compatriots seem to think, and whether he has had more than rare run ins with the hospital staff quality/practice review committees. My own patients’ encounters with the other physician/surgeon make up a small portion of his/her patient experience and as such may be biased either in favor or against that practitioner. I would like to think that my assessment of competence and quality of another doctor is valid, but I really have no easily available robust, concrete basis upon which to base my opinions

Who else is looking at quality and quality measures?

There are many groups looking at some measure of hospital or practitioner quality. For hospitals, the Joint Commission has its ORYX process measure tool; the CMS has its “Hospital Compare” data base[5], which provides information on utilization of process measures and outcomes such as mortality, 30 day readmission rate as well as some cost measures – but these are only for some clinical conditions (Acute Myocardial Infarction (heart attack), Congestive Heart Failure (CHF), pneumonia and Surgical Infection). There several coalitions of purchasers of healthcare (often employer groups) that look at their measures of quality: The Leapfrog group[6], a business purchasing group, just released results of a survey of quality metrics for approximately 1,200 hospitals,[7]. Some of the data on these measures were from publicly available sources and some from questionnaires filled out by some branch of the many of the hospitals. When a group of hospitals “failed” the leapfrog card they immediately questioned the methodology [8] . Many lay publications (Consumer Reports adn US News and World Reports among others) also have their own construct of what they call quality.

it would be ideal if many of the at least 9 stakeholder groups that look at quality could agree on a standard set of measures that may be revised periodically (but not too often). Thus, physicians, hospitals/systems, and other providers could keep a single series of quality measures that would satisfy the myriad people who want to report and depend on reports for making judgments on whom to use as a referral. Some groups such as the American Heart Association (through their Get with the Guidelines program [9] for some heart conditions, The American Board of Internal Medicine (with its Maintenance of  Certification) among others are trying to standardize process measures. If these are adequate, then other groups (like CMS and state licensing boards) should be able to incorporate satisfaction of these measures into their own requirements without “tweaking” them, which often leads to redundancy and increasing difficulty in keeping up with reporting.

Sources:

[1] Feinstein, Alvin R: Clinical Judgment; 1967 Williams Wilkins Co, Baltimore.

[2] Donabedian A. Evaluating the quality of medical care. Milbank Memorial Fund Quarterly 1966; 44:166-206

[3] Donabedian, A. The Quality of Care: How Can It Be Assessed?  JAMA 1988; 260; 1743-1748

[4] www.nap.edu/html/quality_chasm/reportbrief.pdf
http://www.nap.edu/openbook.php?record_id=10027&page=5

[5] http://www.medicare.gov/hospitalcompare/

[6] www.leapfroggroup.org/

[7] http://www.leapfroggroup.org/news/leapfrog_news/4810593

[8] http://www.ama-assn.org/amednews/2012/12/31/prsa1231.htm

[9] http://www.heart.org/HEARTORG/HealthcareResearch/GetWithTheGuidelinesHFStroke/Get-With-The-Guidelines—HFStroke_UCM_001099_SubHomePage.jsp